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This case involves several issues related to standard of care and possibly to causation, which are subject to review by the facilitys risk manager.
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Five years after the landmark Institute of Medicine report, To Err is Human: Building a Safer Health System, not enough is being done to address medication errors, warns the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA.
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Liquids on floors represent the biggest risk for falls in health care facilities, but risk managers often overlook the need to assess the fall risk of a particular area with wet surfaces, not dry ones, says an expert.
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The 2003 transplant error at Duke University Hospital in Durham, NC, that led to the appointment of a new patient safety officer at Duke University Hospital System in Durham, NC, was traced to a lack of redundancy in the system that ensured donor organs matched the patient.
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This case primarily deals with the issues of delay in diagnosis and delay in informing the patient of test results and the appropriate diagnosis. Communication with patients is critical and, if not handled properly, can be disastrous.
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Los Angeles County officials reported recently that a patient at Martin Luther King Jr./Drew Medical Center died after a nurse turned down an audio alarm on his vital signs monitor and then failed to notice that he was having a heart attack.
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The movement to prevent wrong-site or wrong-person surgery got another boost recently when a major health plan announced that on Jan. 1, 2005, it will stop paying for medical procedures involving those egregious errors.
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Anesthesia awareness is not just a problem for the anesthesia department. That was a key message of JCAHO when it issued its recent Sentinel Event Alert on the issue.
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A terrifying failure during general anesthesia, once thought to be so rare that it did not warrant much attention, actually is common enough that risk managers should launch a specific, focused effort at reducing the problem, known as anesthesia awareness.
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One of the best ways to thwart any attempt at stealing nuclear materials from your facility is to take seriously any report of missing material, says the president of the International Association for Healthcare Security and Safety in Glendale Heights, IL.
